Family Physicians Can Cut Unnecessary Surgeries

In 1954, JAMA published an article(archsurg.jamanetwork.com) that explored unnecessary and inadequate breast cancer surgery. In those days, surgeons favored more aggressive procedures such as radical mastectomies with removal of a high number of lymph nodes.

We have this knowledge because of strides made in evidence-based medicine -- specifically, robust clinical trials that demonstrate relevant outcomes of surgery. Does the surgery extend a patient's life? Does the surgery decrease a patient's pain? Does it improve the patient's quality of life?

Answering these questions, along with weighing risks and other treatment options, should help guide decisions regarding whether to pursue surgery. But even with better data, unnecessary surgeries are still common.

Even otherwise life-extending surgeries can be considered unnecessary when performed in the wrong patient populations because they provide only dubious benefits. A 2011 JAMA study(jama.jamanetwork.com) found 22.5 percent of people who received an implantable cardioverter-defibrillator did not meet evidence-based criteria for implantation. These patients had a higher risk for complications and longer hospital stays.

So what is driving unnecessary surgeries? Simply put, the fee-for-service health care system rewards physicians and facilities for doing more procedures. And surgeons feel an implicit expectation that, by the time patients reach them, they are leaning toward an operation.

Family physicians can play a prominent role in counseling patients on surgical and nonsurgical treatment options. We are able to take a holistic, unbiased and evidence-based view. However, many primary care physicians defer to a surgeon to provide education because of time constraints in the current fee-for-service environment. Educational sessions with decision aids are often difficult to fit into a 15-minute office visit.

Patients also play a role in the demand for surgeries of questionable value. Our culture has convinced patients that more care equals better care. Every family physician knows the delicate art of debunking that dogma.

I recently had a patient with classic low back pain. Her physical therapy sessions were a time-consuming part of her busy schedule, and she was tired of taking OTC meds. She requested a consult with a spinal surgeon. Knowing this wasn't the best option, I encouraged her to try a few more session of PT, weight loss and even consider nontraditional treatments such as acupuncture. But the patient wanted a quick, aggressive fix and I suspected she felt as though my resistance to refer meant I was withholding care from her. So I referred her to a surgeon I knew would reiterate what I already had advised.

So how do we create a system that curbs unnecessary surgeries? The burden cannot fall on our surgery colleagues alone; it will require system changes.

A team-based approach to care offers a reasonable solution. Consistent messaging from the patient's primary care physician, subspecialist and other clinicians involved in the patient's care may demonstrate which treatments are ineffective and which are supported by research.

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